Paul G. Auwaerter, MD

Disclosures

October 20, 2011

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Hello. This is Paul Auwaerter from Johns Hopkins University speaking for Medscape Infectious Diseases today on the jam-packed annual meeting of the Infectious Diseases Society of America in Boston in October 2011. Given the short period of time that I have today, this is a capricious list, but I thought I would highlight a couple of interesting trends and observations and perhaps studies that could be of interest to you as a clinician.

The first is an interesting vaccine debate: HPV [human papillomavirus] immunization in males.[1] Recently, HPV immunization has taken a bit of a political tack in the Republican debate, but the vaccine, although effective in male patients, raises issues as to whether its effectiveness is worth the cost or potential consequences as part of vaccine policy. There is no doubt that it is effective, and this session by Kevin Ault will address those issues.

The second is a late-breaking abstract.[2] By conflict of interest I should mention that the author, Mark Sulkowski, is from Johns Hopkins, but this abstract is important because it looks at the new HCV [hepatitis C vaccine] drug boceprevir in co-infected patients with HIV and HCV when combined with pegylated interferon and ribavirin. There have been precious little data in co-infected patients. This study looked at 100 patients who were randomly assigned to a boceprevir or a nonboceprevir arm. The conclusions were that patients who received boceprevir tolerated it well, and these patients were also on suppression ART [antiretroviral therapy] programs for HIV. At week 12, approximately 60% had undetectable HCV viral load -- a 33% higher response rate in patients taking boceprevir. This is obviously a smaller study but important news for anybody who has HIV-infected patients who also have HCV infection.

The balance of my comments point to the growing issues with respect to antimicrobial resistance. Clearly gram negatives are among the greatest worries, with many presentations and posters looking at epidemiology, resistance, and potentials for treatment as well as drug shortages. I would like to point out 3 interesting issues. One is an oral abstract, number 161,[3] which looked at a survey of infectious diseases (ID) clinicians and whether they experienced drug shortages in the last 2 years. Of 503 ID clinicians responding, 78% said that they had to alter their practice in the last 2 years. The top 4 offenders (probably no surprise to any of you) are trimethoprim/sulfamethoxazole, amikacin, aztreonam, and foscarnet. Respondees commented that when they had to use different drugs, it resulted in toxicities; unnecessary use of broader-spectrum agents; increased coughs; increased length of stay; and 30% cited that their patients had inadequate response to treatment. Obviously, this is a survey rather than a strict study, but certainly it portends to problems that we are dealing with -- not only the resistant organisms, but we often don't have the right drugs to treat them.

Another interesting issue is addressed in poster 256.[4] What do you do when you have KPC [Klebsiella pneumoniae carbapenemase]-resistant organisms as well as colistin-resistant organisms at a very high level? This is an issue that very few of us know anything about. Annie Farrell and colleagues from Pittsburgh did in vitro studies using checkerboard analyses and found that the combined use of colistin, doripenem, and ertapenem all yielded 100% synergistic response rates. They postulated that this could be because KPC's high affinity for ertapenem allowed other drugs to work. They found that, to a lesser degree, doripenem and doxycycline as well as doripenem and rifampin were also effective. Obviously, these aren't in vivo results, but perhaps something that might be considered if you are faced with such a terrible organism.

Lastly, a late-breaking abstract (number 279) by Helen Boucher[5] looks at what is coming down the pipeline: 9 drugs in various stages of development for gram-negative organisms. Of importance are a number of beta-lactamase inhibitors that are complexed with other drugs such as ceftaroline, as well as a new aminoglycoside and 4 new completely novel compounds that might represent good and effective new drug classes. Clearly, none of these are yet in clinical use but represent perhaps some hope on the pipeline. Obviously, this will be a big meeting with lots of information well done by the organizers and the many presenters. Thanks for listening.

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